Willingness to use electronic medical record (EMR) system and its associated factors among health professionals working in Amhara region Private Hospitals 2021, Ethiopia

Introduction Despite the high expectations of electronic medical records as a great prospect for improving performance in healthcare, the level of adoption and utilization, particularly in a developing country, is low. Knowing the willingness to use the electronic medical record system in the private hospital has an impact on the future implementation status and utilization of the electronic medical record in Ethiopia. However, there was no evidence of the status of the willingness to use electronic medical record systems in private hospitals in the Amhara region. This study aimed to assess the willingness to use electronic medical record Systems and its associated factors among health professionals working in Amhara Region Private Hospitals. Methods A cross-sectional institutional study was performed among 406 health professionals selected using proportional allocation with a simple random sampling technique in Amhara region private hospitals by using self-administered structured questionnaires. The data were analyzed using SPSS version 20 software. Descriptive statistics and binary logistic regression were performed to estimate the crude and adjusted odds ratios with a 95% Confidence interval. Results Out of the 406 participants included in the analysis, 307 (75.6%) showed a willingness to use the electronic medical record system. About three hundred twelve (76.8%) health professionals had good knowledge of electronic medical record systems, and 257 (63.3%) had good computer skills in electronic medical record systems. Health professionals who had electronic medical record knowledge (AOR = 1.85, 95% CI (1.004–3.409)), EMR training (3.29, 95% CI (1.353–8.003)), technical support personnel (1.92, 95% CI (1.122–3.305)), supportive supervision (AOR = 1.97, 95% CI (1.072–3.628)), and computer skill on electronic medical record (1.77, 95% CI (1.002–3.148)) were significantly associated with the outcome variable. Conclusions This finding shows a good proportion of willingness to use the electronic medical record system. The most significant factors associated with willingness to use the electronic medical record system were a lack of computer skills, computer training, and knowledge of the electronic medical record system.


Introduction
Despite the high expectation in EMR as a great prospect for improving performance in healthcare, the level of adoption and utilization particularly in a developing country is low. Knowing the willingness to use the EMR system in the private hospital has an impact on the future implementation status and utilization of the EMR in Ethiopia. However, there was no evidence of the status on willingness to use electronic medical record system in private hospitals in the Amhara region. This study aimed to assess the willingness to use electronic medical record Systems and its associated factors among health professionals working in Amhara Region Private Hospitals. Methods A cross-sectional institutional study was performed among 406 health professionals selected using proportional allocation with simple random sampling technique in Amhara region private hospitals by using self-administered structured questionnaires. The data were analyzed using SPSS version 20 software. Descriptive statistics with Binary logistic regression was performed to estimate the crude and adjusted odds ratio with a 95% Confidence interval. Results Out of 406 participants included in the analysis, 307 (75.6%) participants showed a willingness to use the EMR system. 312 (76.8%) health professionals had good knowledge of EMR systems and 257 (63.3%) had good computer skills on EMR systems. health professionals who had EMR Knowledge (AOR=1.85, 95% CI (1.004-3.409)), EMR Training (3.29, 95% CI (1.353-8.003)), technical support personnel (1.92, 95% CI (1.122-3.305)), supportive supervision (AOR=1.97, 95% CI (1.072-3.628)), and Computer skill on EMR (1.77, 95% CI (1.002-3.148)) were significantly associated with the outcome variable. Conclusions This finding demonstrates a high proportion of willingness to use the EMR system. Knowledge, skill, training, technical support personnel, and supportive supervision were significantly associated with the outcome variable. Stockholders should focus on continuous follow-up, adequate training, and technical support of health professionals.

Abstract Introduction
Despite the high expectation in EMR as a great prospect for improving performance in healthcare, the level of adoption and utilization particularly in a developing country is low. Knowing the willingness to use the EMR system in the private hospital has an impact on the future implementation status and utilization of the EMR in Ethiopia. However, there was no evidence of the status on willingness to use electronic medical record system in private hospitals in the Amhara region. This study aimed to assess the willingness to use electronic medical record Systems and its associated factors among health professionals working in Amhara Region Private Hospitals.

Methods
A cross-sectional institutional study was performed among 406 health professionals selected using proportional allocation with simple random sampling technique in Amhara region private hospitals by using self-administered structured questionnaires. The data were analyzed using SPSS version 20 software. Descriptive statistics with Binary logistic regression was performed to estimate the crude and adjusted odds ratio with a 95% Confidence interval.

Conclusions Introduction
All over the world, Health Information Systems (HIS) and technologies are getting used increasingly and are seen as a good way to increase health system performance and the quality of patient care(1). HIS enable healthcare worker to document relevant patient records and offer an efficient and advanced healthcare service (2). Healthcare organizations achieve these outcomes through the use of HIS such as Electronic Medical Records (EMR), telehealth, mobile health applications, and health information management systems (3). The most important contribution of EMR is that a patient can have one electronic data that can be accessed at any time within a single health care delivery organization and also EMR enables faster work, Fewer errors, Prevent the loss of data, Ensuring confidentiality, Continuity of care, and improving the overall health care system but in the same wise there are potential cons such as Security, Confidentiality and others like crashes and power-cuts (4).
The national wide e-health approach toolkit developed through the world health organization (WHO) and International Telecommunication Union (ITU)(5) defines EMR as "a computerized medical record used to capture, store, and share information among healthcare providers in an organization, supporting the delivery of health services to patients". even though there may be an excessive expectation and need in EMR as a great prospect for improving high-quality, continuity, safety, and performance in healthcare, the general adoption status particularly in a developing country is low (6). Many reasons can be given to the low utilization and adoption of EMR in Ethiopia, but the main ones are related to skill gap, Lack of awareness and knowledge, Lack of availability of technical support and infrastructure, perception, willingness, attitude, technology resistance, and administrative problems have slowed the process of implementation and adoption of EMR (7,8). The unwillingness of health professionals to accept and utilize digital health information systems and electronic medical records might be one of the essential obstacles that hinder the successful implementation and utilization of electronic health information systems.
Knowing the willingness to use the EMR system in private and public hospitals has an impact on the future implementation status and utilization of the EMR system in Ethiopia (9). Particularly this study focuses on the private health facilities since the attention was not given to the private hospitals towards the willingness of EMR system with evidence-based research. The Ethiopian government needs to digitalize public as well as private health facilities and also needs to strengthen the public-private partnership. Public-private partnership in health (PPPH) was an element of the Ethiopian health sector transformation plan (10,11). The overall policy environment supports private sector engagement and public-private partnerships (12,13). Health Policies and strategies in Ethiopia are focused on the material aspect particularly the installations and infrastructure of EMR systems and have ignored the attitudinal and behavioral factors (willingness) of healthcare professionals in using the EMR system in private as well as public hospitals (9).
To overcome the issues related to EMR and to facilitate the adoption and use of innovative technologies, it is very important to understand the factors that affect the willingness to use the EMR system by health professionals in healthcare.
Health professionals' understanding, knowledge, willingness, and mindset on EMR use are vital elements that could impact its future fulfillment (14).
Studies have shown that a lack of knowledge, skills, availability of skilled human capital, resource availability, computer literacy, English language proficiency, 5 educational status, and training are the factors that potentially affect the willingness to use EMR systems by the healthcare professionals (9). Most of the problems are related to the unwillingness of its users to accept the transition from paper-based to electronic systems. This has contributed to the failure costs of many EMR installations (6).
In the Ethiopian health system, the majority of private health facilities are found in the urban area and also majority population seeks health service from the private health facility, but most of the time the data documentation process regarding quality is not the same as the government health facilities because the private health facilities are not taking the mandates as the governmental hospital to report the data to the concerned body or FMOH (federal ministry of health). With the burden of increased service users and disease private hospitals' information quality and utilization for decision-making remain vulnerable and weak (9), this is because private EMR infrastructure is stimulated by a reluctance to use already existing technology (15).
Having electronic medical records systems in many health organizations improves the efficiency of health care delivery and availability of health information at any time and also retrieves patient information for patient care, statistics, research, and teaching (16,17). Therefore adopting EMR in a private health facility is one of the digital technologies that can successfully transform the health system by reducing the public or governmental health facility burden by making the service fast, easy and accurate in the private sector.
There is no study conducted in the Ethiopian context on the willingness to use EMR among health professionals working in private hospitals. Therefore, this study aims to assess the willingness to use electronic medical record (EMR) systems and its associated factors among health professionals working in Amhara Region Private Hospitals.

Study design and setting
A cross-sectional institutional study was performed from January 25 to February 20, 2021. The study was conducted in private hospitals found in the Amhara region. The Amhara Region is located in the northwestern part of Ethiopia and the region is divided into 13

Sampling procedures
The sample size of this study was determined using a single population proportion formula: considering the following assumptions: 95% level of confidence, 5% margin of error, and 10% non-response rate, proportion (p) of 50% of willing to use the EMR system. Finally, a sample size of 423 was obtained. The source population was all health professionals working in private hospitals in the Amhara region and the study population was selected health professionals who had been working in ten private hospitals of the Amhara region. Health professionals who were working less than six months and who were working both at private and governmental health facilities were excluded to avoid bias.
There were ten private hospitals in the Amhara region. From each hospital permanent health professionals working during the study period were included in the study; proportional allocation was done for each hospital according to the 7 actual number. Each healthcare worker in each private hospital was selected by simple random sampling from a list of medical staff administrative records.

Operational definition
Knowledge: -Knowledge was measured on a 5-point Likert scale ranging from 'strongly disagree' (score 1) to 'strongly agree' (score 5). Thirteen knowledge questions were added and divided by 13 to create a composite variable scale (ranging from score 1 to 5) for data analysis. Finally, the composite variable score was dichotomized as 'good knowledge' or 'poor knowledge' based on the final score. Accordingly, a final score of the above three (agree and strongly agree) were categorized as 'good knowledge' while those final scores of three or below (strongly disagree, disagree, and neutral) were categorized as 'poor knowledge' (18) Willingness to use:-Willingness of health professionals to use the EMR system was rated into "willing" and "not willing" using composite scores obtained from all the five willingness questions (9), Five questions were scored, and the maximum score obtainable is 5 marks. A score of 3 marks and above out of 5 marks suggests willingness while a score of less than 3 marks suggests an unwillingness to use the EMR system (9).
Computer skill: -skill was measured on a 5-point Likert scale ranging from 'strongly disagree' (score 1) to 'strongly agree' (score 5). Each skill question was added and divided by the number of questions to create a composite variable scale (ranging from score 1 to 5) for data analysis. Accordingly, a final score of above three (agree and strongly agree) was categorized as 'good skill' while those final scores of three or below (strongly disagree, disagree, and neutral) were categorized as 'poor skill' (18).

Data collection tools and procedures
Self-administered structured questionnaires were used to gather quantitative data by using questionnaires adapted from (9,19

Ethical approval and consent to participate
The study protocol was reviewed and obtained from the ethical review committee of the University of Gondar College of Medicine and Health Science, Institute of Public Health. A supporting letter was also obtained from the Amhara Regional Health bureau. Informed written consent was obtained from each study participant after telling the objective of the study. They were also informed about the benefits of the study. The data collection was anonymous and the information was kept confidential. were nurses by profession, and 150 (36.9%) of participants' monthly income ranges from 5251-7800 Birr (Table 1). access to take EMR system training ( Figure 1).  (Table   3).  Table 4) and (Figure 2).

Factors Associated with Willingness to Use the EMR System
Bivariable and multivariable binary logistic regression analyses were done to determine the association between the willingness to use the EMR system and independent variables. Accordingly, those variables which had a p-value of less

Discussion
This institution-based cross-sectional survey was conducted to assess the health professional willingness to use EMR and to identify factors affecting willingness to use EMR in private hospitals of the Amhara region.
The respondents of this study confirmed a good willingness toward the usage of EMR. According to these findings, health professionals who were willing to use the EMR system in private hospitals were 75.6%. This finding is in line with a study carried out in private hospitals of India, where 75% were comfortable working on EMRs (13). However, the result of this study is lower than that of a study conducted in Nigeria (Lagos) (19) and in Kenya (20 (6,21).
In this study, health professionals who had good knowledge of the EMR systems were more likely willing to use the EMR system as compared to those with poor knowledge of the EMR system. This may be because health professionals who had good knowledge may tend to accept the advantage of technology and be likely to be willing to use the EMR system. As discussed in other studies (9,22,23) health professionals who have good knowledge of the EMR system were more likely willing to use the EMR system than their counterparts or have poor knowledge of the EMR system. This is also a good explanation for the need to create awareness and strengthen continual capacity building among less knowledgeable health professionals, to narrow the knowledge gaps found about the EMR systems so that they will have a good willingness to use EMR and develop their knowledge for better use of the EMR system.
Despite the differences in the study participants, experience and availability of a computer EMR training were significantly associated. Health professionals who had trained EMR system were more likely willing to use the EMR system as compared to those health professionals who had not trained any EMR system before, and this is in line with other findings (9,22,(24)(25)(26) this explained by the evidence that training and education usually change people's views, willingness, knowledge, and skills of health professionals on EMR systems (19). 19 Computer skill is the pillar of information communication and EMR utilization in the healthcare system; for this reason, more than half (63.3%) of the respondents in the current study were with good skills in computer application. other studies have indicated that there is a relationship between the level of IT skills and the willingness to use electronic medical records and this study was no exception.
Respondents whose computer skill was good were more likely willing to use the EMR system than poor computer skill. This finding was in line with the study findings from Ethiopia (9, 23), Nigeria (19,27). This is because those health professionals with good computer skills and the availability of computers had a direct influence on health professionals' views on computer-based system use.
Availability of adequate computers, other resources, training centers, and support from the different organizations were also the likely explanations for the similarity of being a good skill.
Reliable and timely health information is the foundation of health systems action where information and communication technology initiatives such as EMRs enhance the decision-making process. However, it is sometimes not available when required because of poor supportive supervision (M&E). However, supportive supervision was significantly associated with willingness to use EMR in none of our literature. This study truly explained the fact that supportive supervision was an independent determinant for willingness to use the EMR system. This is because technical support supervision involves identifying or equipping a relatively smaller team of technical staff with the relevant skills-set, the right tools, and resources Thus, for the private as well as public health sector to enhance the effectiveness and efficiency of supportive supervision, the technical support supervision approach should be adopted with a major focus on identifying the skill gaps among the technical staff at all levels, Equipping the technical staff with the relevant skills-set, Motivating and retaining technical staff at all levels of health care and Facilitating the technical teams with the right tools' resources(28). For this reason, about 52.2% of the respondents in the current study were working in the presence of technical support personnel, and respondents working in the presence of technical support personnel were more likely willing to use EMR systems than their counterparts. This finding is supported by the other study from Ethiopia (29), and Saudi Arabia (30). Probably this may happen as long as individuals got access to technical support their willingness to use a computer would increase because technical support would increase technical skill and this will lead to the willingness to use the EMR system. To alleviate this problem adequate training and technical support should be given to health professionals.

Conclusion
The majority of the healthcare professionals showed a better willingness to use the EMR system. However; lack of computer skills, lack of computer training, lack of technical support personnel, lack of EMR system knowledge, and supportive supervision (M&E) were found as factors to affect the willingness to use EMR systems by health professionals. Therefore, stakeholders should enhance EMR training, focus on continuous follow-up, and offer technical support for health professionals.

Author's contributions
AF substantially contributed to the conception and design, analysis, and interpretation of the study. BT, AM SM, and KS were involved in the analysis, interpretation, and all authors participated in drafting the article or revising it critically for important intellectual content, gave final approval of the version to be published.